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Vol. 22 Issue 20


Coming Soon: New Member Benefit Coming from LeadingAge Florida - Beginning in September 2015 as a member benefit, LeadingAge Florida will send nursing home members a facility-specific report on a quarterly basis that will provide a comprehensive analysis of their 5-Star rating.

The recent Centers for Medicare and Medicaid Services (CMS) changes to the Nursing Home Compare 5-Star Quality Rating System report caused many organizations to move down in star ratings without a detailed explanation of why.

The reports will explain the 3 components of the 5-star rating, including inspections, staffing hours per resident day, and the 11 quality measures. The reports also will indicate where members can focus efforts to both improve resident care and to increase their 5-Star rating.

Take a look at a sample Nursing Home 5-Star Analysis report. Also, be sure to check out the LeadingAge Insights page for other tools to help members better understand their own performance and their market position. With the added advantage of easy access to experts in the field, these tools help members improve their performance and competitiveness. Operated as a partnership of LeadingAge and LeadingAge Florida, these tools are available free of charge to LeadingAge provider members.

Click here to register for an upcoming training webinar on How to Interpret Your New 5-Star Analysis Report scheduled for September 22, 11:00am to noon and September 29, 2:00 to 3:00pm.


CMS to Extend Initiative to Improve Care for Nursing Facility Residents - The Centers for Medicare & Medicaid Services (CMS) today announced a new funding opportunity designed to enhance the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents. The funding opportunity will allow the organizations currently participating in the Initiative to apply to test whether a new payment model for nursing facilities and practitioners will further reduce avoidable hospitalizations, lower combined Medicare and Medicaid spending, and improve the quality of care received by nursing facility residents.

For the past three years, CMS has partnered with seven Enhanced Care and Coordination Providers (ECCPs) to test a model to improve care for long-stay nursing facility residents. The ECCPs collaborate with 144 nursing facilities across seven states—Alabama, Indiana, Missouri, Nebraska, New York, Nevada, and Pennsylvania—to provide on-site staff for training, to provide preventive services, and to improve the assessment and management of medical conditions (see fact sheet).

The intent of the new payment model is to reduce avoidable hospitalizations by funding higher-intensity interventions in nursing facilities for residents who may otherwise be hospitalized upon an acute change in condition. Improving the capacity of nursing facilities to treat medical conditions as effectively as possible within the facility has the potential to improve the residents’ care experience at lower cost than a hospital admission. The model also includes payments to practitioners (i.e., physicians, nurse practitioners and physician assistants) similar to the payments they would receive for treating beneficiaries in a hospital. Practitioners would also receive new payments for engagement in multidisciplinary care planning activities.

“This Initiative has the potential to improve the care for the most frail, most vulnerable Medicare-Medicaid enrollees—long term residents of nursing facilities,” said Tim Engelhardt, Director of the Medicare Medicaid Coordination Office. “By aligning financial incentives, we can improve the quality of on-site care in nursing facilities and the assessment and management of conditions that too often now lead to unnecessary and costly hospitalizations.”

This new four-year payment phase of the Initiative, slated to begin October 2016, will be subject to a rigorous external evaluation to determine the effects on cost and quality of care. Successful ECCP applicants would implement the payment model with both their existing partner facilities, where they provide training and clinical interventions, and in a comparable number of newly recruited facilities.

The Initiative is a collaboration of the CMS Medicare-Medicaid Coordination Office and the Center for Medicare and Medicaid Innovation, both created by the Affordable Care Act to improve health care quality and reduce costs in the Medicare and Medicaid programs. The Initiative complements broader administration efforts to improve long term care facilities, including proposed updates to the conditions of participation for nursing homes, improvements to the five star rating system for consumers, and implementation of the new Skilled Nursing Facility Quality Reporting Program that ties skilled nursing facility payment to the reporting of quality measures.

Click here to view the CMS Fact sheet.

CMS Conducts Final Successful Medicare FFS ICD-10 End-to-End Testing Week in July - From July 20 through 24, 2015, Medicare Fee-For-Service (FFS) health care providers, clearinghouses, and billing agencies participated in a third successful ICD-10 end-to-end testing week with all Medicare Administrative Contractors (MACs) and the Durable Medical Equipment (DME) MAC Common Electronic Data Interchange (CEDI) contractor. CMS was able to accommodate most volunteers, representing a broad cross-section of provider, claim, and submitter types.

This final end-to-end testing week demonstrated that CMS systems are ready to accept and process ICD-10 claims. Approximately 1,200 providers and billing companies participated, and testers submitted over 29,000 test claims. View the results.

Overall, participants in the July end-to-end testing week were able to successfully submit ICD-10 test claims and have them processed through Medicare billing systems. The acceptance rate for July was similar to the rates in January and April, but with an increase in the number of testers and test claims submitted. Most of the claim rejections that occurred were due to errors unrelated to ICD-9 or ICD-10.

Through its robust system release testing, CMS has ensured that the Medicare FFS claims processing systems changes for ICD-10 implementation have been thoroughly tested and validated. CMS also has conducted an unprecedented additional level of testing to help providers prepare for ICD-10. This was the final end-to-end testing week, but providers are encouraged to participate in acknowledgement testing, which can be completed at any time prior to the implementation date.

Be Prepared -- Medicare claims with a date of service on or after October 1, 2015, will be rejected if they do not contain a valid ICD-10 code. The Medicare claims processing systems do not have the capability to accept ICD-9 codes for dates of service after September 30, 2015; or accept claims that contain both ICD-9 and ICD-10 codes.

CMS has created a number of ICD-10 tools and resources for providers. One tool is the “Road to 10,” aimed specifically at smaller physician practices with primers for clinical documentation, clinical scenarios, and other specialty-specific resources to help with implementation.

For more information, visit the Medicare FFS Provider Resources web page.

CMS Proposed SNF Rule - LeadingAge Florida is working closely with LeadingAge on the CMS proposed rule changes for regulations governing nursing homes. Cheryl Phillips, M.D., and Evvie Munley of LeadingAge developed the following information and are encouraging members to submit comments on these “big topic” items.

By now, most of you who provide nursing home care are aware of the extensive proposed rule CMS released on July 16, to revise the Requirements of Participation for nursing homes. There have been several notices and articles posted on the LeadingAge web site encouraging you to submit your comments. To make it a little easier, here is a BRIEF summary of the overarching areas and some of our high level concerns. It is VERY important CMS hears from you, the providers. We will submit a formal letter of comment that goes through each issue, line-by-line, however, nothing is as impactful as your story! In this case, volume matters. You do not have to write a lengthy letter covering everything. You may pick one or two issues and tell CMS what this would mean to your community and how it would impact your staff, your residents and their families.

Here are the “big topic” items:
  • Quality Assurance and Performance Improvement (QAPI) with the requirement for a QAPI plan to be in place. (483.75)
  • Compliance and Ethics program requirements to implement 2010 mandate for compliance programs. (483.85)
  • Extensive infection control requirement that involves significant staff training and additional “expertise.” (483.80)
  • A required facility-wide assessment that will be used to determine “sufficient staff.” While the format of this assessment requirement is left unclear, we have to assume that any issues identified at the time of survey will likely link back to whether or not there was an adequate assessment of resident needs with regard to staffing. (483.70)
  • SIGNIFICANT staff training requirements, including culturally competent, trauma-informed care, again leaving many of these competencies undefined and open to surveyor interpretation. (483.95)
  • Detailed clinical practice regulations, including an in-person evaluation by a physician, physician assistant, nurse practitioner or clinical nurse specialist prior to non-emergent hospital transfer; notification to the attending physician of ALL abnormal lab and X-ray results; renewal of PRN orders every 48 hours; and an assumption about attending physician credentialing. (483.30)
  • Broad changes in behavioral health services. (483.95)
  • Expanding the requirements for antipsychotic medications to include ANY psychoactive medication, including antidepressants and opioid pain meds. All with the requirement to have gradual dose reductions. (483.45)
  • Dramatic requirements for physical environment / reconstruction. (483.75)

We support the person-centered intent of some of these new proposed rules (for example, trauma-informed care). However, as indicated above, many of these requirements are vaguely defined and subject to surveyor interpretation or assume new staff competencies that are also not well defined. In several instances, CMS has taken what should be ideal clinical practice goals and elevated them to requirements, even when they can be impossible to achieve by most homes.

We believe that, while many of the proposed requirements are already part of your practice, the issues listed above are far-reaching. There is considerable ambiguity that will set the stage for variation by surveyors from region to region.

We believe these changes cannot be reasonably implemented all at one time, and should, at a minimum, allow for a phase-in over five years. In addition to the complexity of many of the new processes and procedures, we believe many of the requirements for specific staff expertise will be impossible for rural homes or those in workforce shortage areas to meet in a short time frame.

We believe CMS significantly underestimated the staff time and cost of compliance with these rules. It is important that they hear from non-profit providers to understand how many of these proposed rules would disadvantage the local, community-based, non-profit homes and risk many will simply have to close their doors.

Below is a link where you may submit your comments electronically to CMS. Remember, these do not have to be lengthy or comprehensive – just pick an issue or two that you are most concerned about and share it with CMS. In addition, remember to ask for a phase-in of the final rule - that will help keep our message consistent.

And two additional important requests from LeadingAge

  • We are very interested in your current facility assessment process. If you would tell us in a few words how you determine staffing needs – it would be very helpful in developing our recommendations to CMS.
  • Please send us a copy of your comments to CMS so that we, too, can integrate your voice into our final letter.

Comments to CMS must be received by 5pm EST September 14 and can be submitted electronically by clicking on the following link: Please refer to file code CMS–3260–P in your comments.

As always, if you have any questions, do not hesitate to reach out to Evvie Munley at (202) 508-9478 or Cheryl Phillips at (202) 508-9470.

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